Uncategorized

One of the terms that you’ll see used to describe health quackery, scams and pseudoscience is “snake oil”. Snake oil was a real product, sold in the early 19th century as a cure-all elixer in the “patent medicine” era. Popularized in movies, the snake-oil salesman would pull into town, and start the hard sell for his product that was promised to CURE everything from aches and pains to sore throats and dislocations. The original products apparently did contain snake, but soon other products appeared on the market that didn’t even contain any snake – they were an assortment of ingredients concocted to smell medicinal and seem medicinal, but had no therapeutic effects. These small-town sideshows would hype the products and try to sell as much as possible. In 1905 an article in Colliers exposed the patent medicine industry for what it was – health fraud. The Pure Food and Drugs Act (in the USA) followed, and eventually, modern drug regulations emerged as we know them today.

Is the health care spending tide turning? Unnecessary medical investigations and overtreatment seems to have entered the public consciousness to an extent I can’t recall in the past. More and more, the merits of medical investigations such as mammograms and just this week, PSA tests are being being widely questioned. It’s about time. Previous attempts to critically appraise overall benefits and consequences of of medical technologies seem to have died out amidst cries of “rationing!”, particularly in the United States. But all health systems are struggling to manage unsustainable cost increases. But this time, the focus has changed – this isn’t strictly a cost issue, but a quality of care issue. It’s being championed by the American Board of Internal Medicine Foundation (ABIM) under the banner Choosing Wisely with the support of several medical organizations. The initiative is designed to promote a candid discussion between patient and physician: “Is this test or procedure necessary?”. Nine organizations are already participating, represent nearly 375,000 physicians. Each group developed its own list based on the following topic: Five Things Physicians and Patients Should Question. Here are the lists published to date:

ABIM has partnered with Consumer Reports to prepare consumer-focused material as well, so patients can initiate these discussions with their physicians. How did this all come to be? A candid editorial from Howard Brody in the New England Journal of Medicine in 2010:

In my view, organized medicine must reverse its current approach to the political negotiations over health care reform. I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty’s “Top Five” list. The panels should include members with special expertise in clinical epidemiology, biostatistics, health policy, and evidence-based appraisal. The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.

Health care professionals are, in general, self-regulating professions. That is, governments entrust them to set the standards for their profession and regulate members, in the public interest. Consequently, attempts by payors of services (i.e., government and insurers) to guide medical practice are usually met with substantial resistance. No-one wants insurers interfering in the patient-physician relationship. That’s why it’s exciting to see this initiative in place: It’s being driven by the medical profession itself.

As a pharmacist I’m also a member of a self-regulating profession, one in which the public places a considerable degree of trust in. In order to maintain the public’s confidence, it is essential that the pharmacy profession maintain the highest professional and ethical standards, and do its part to reduce unnecessary testing and investigations. With this in mind, I’ve taken up Brody’s challenge and developed my own list of Five things Pharmacists and Patients Should Question. While eliminating them may not provide the most savings to patients, they are pharmacy-based, widely offered, and offer little to no benefit to consumers. Here are my top five candidates: Continue reading →

This is the first of a series of posts adapting a presentation made at The Ontario Public Health Convention in April, 2011. The presentation, “Fighting in the Trenches: Countering Anti-Vaccine Sentiment with Social Media” was a panel discussion from Scott Gavura and Kimberly Hébert:

One of the best parts of the infectious disease outbreak movie Contagion was the decision to include an antivaccinationist, conspiracy-minded, alternative health advocate, played by Jude Law. Law gave a character-perfect performance of someone intent on deliberately and selfishly thwarting public health advice, putting lives at risk as a consequence. Sadly, the writers didn’t have to look far for real world examples: It’s hard to forget “Health Ranger” Mike Adams’s paranoid music video produced in 2009, at the height of H1N1, when he decided to put every antivaccine argument into one performance.

But the Health Ranger is just the current manifestation of antivaccine sentiment which has been around since vaccines were invented:

When a theory has been confirmed so completely by facts as has the proposition that vaccination effectually performed will prevent an individual from contracting small-pox, or at least so fundamentally modify the disease that it is no longer a serious malady, there is in many minds a natural distaste to fight the battle again or to be constantly defending the position against the attacks of ill-informed or prejudiced persons.

– British Medical Journal, July 24, 1897

But this battle is still being fought, after over 100 years of immunization, and over two dozen diseases becoming vaccine-preventable. The anti-vaccine movement is a real movement, and it’s doing what it can to create fear, uncertainty and doubt regarding public health messaging. There is evidence that antivaccinationists can influence vaccination decisions. The arrival of social media over the past decade means there’s the need for public health advocates to adapt their messaging to this new medium. What seems clear is that “traditional” public health tactics, with warnings and arguments from authority, are dwindling in their effectiveness. All aspects of medicine are moving towards models of shared decision-making. This is an overdue change, and it’s been facilitated by the widespread availability of health information. Information is no longer hidden from public access. Want the approved product monograph for a vaccine? It’s available online. Even the primary literature is becoming more freely accessible.

Unfortunately, the power of the Web 2.0 and social media has made it easier for antivaccinationists to foster antivaccine fears and sentiment. In order to combat this misinformation, the movement’s tactics and tropes must be understood, so they can be called out.

As glands go, we don’t give the butterfly-shaped thyroid that straddles our trachea too much thought — until it stops working properly. The thyroid is a bit like your home’s thermostat: turn it high, and you’re hyperthyroid: heat intolerant, a high heart rate, and maybe some diarrhea. Turn it down, and you’re hypothyroid: cold, tired, constipated, and possibly even depressed. Both conditions are associated with a long list of more serious health consequences. Between the two however, hypothyroidism is far more prevalent. The mainstay drug that treats it, levothyroxine (Synthroid), is one of the most prescribed in the world.

One of my more memorable pharmacy experiences involved levothyroxine. The store had recently changed its prescription labelling standards: It switched from listing the brand name, to only including the generic name (with the manufacturer in parentheses). Few patients noticed. But one elderly patient, taking Synthroid, was furious, and accused me of making a dispensing error. I assured her that levothyroxine was the active ingredient in Synthroid, and she was getting the exact same product as her last visit — but she would have none of it. Her symptoms had worsened, she said, because the medication wasn’t the same. “I want Synthroid — this levothyroxine stuff does not work,” she screamed at me across the counter. No amount of reassurance would satisfy her — I think we eventually resorted to custom, typewritten labels.

I mention this anecdote not to dismiss the symptoms of hypothyroidism as sensitive to placebo effects — hypothyroidism is a real condition with objective monitoring criteria. But this episode was one of my earliest lessons in understanding how perceptions can shape expectations of effectiveness — something that I’ll come back to, when we look at the controversies of this common condition. Any the treatment of hypothyroidism is not without its controversies – most of which occur outside the realm of medicine, and can more accurately be labelled pseudoscience. Continue reading →

This year is shaping up to be a challenging one for measles control. Once considered eradicated in North America, it’s seen a bit of a resurgence in the States, almost entirely among the unvaccinated. From the Public Health Agency of Canada: Continue reading →

My stimulant of choice is coffee. I started drinking it in first-year university, and never looked back. A tiny four-cup coffee maker became my reliable companion right through graduate school. But since I stopped needing to drink a pot at a time, an entirely new category of products has appeared — the energy drink. Targeting students, athletes, and others seeking a mental or physical boost, energy drinks are now an enormous industry: from the first U.S. product sale in 1997, the market size was $4.8 billion by 2008, and continues to grow. (1) Continue reading →

As has been repeatedly pointed out on this blog, homeopathy is an elaborate placebo system, with most remedies diluted so greatly that not a single molecule of the original material remains. The final product sold to consumers is quite literally, water – drops of which are dried on sucrose or lactose tablets. The fact that homeopathy has not been shown to be more effective than placebo should surprise no-one: it is a placebo, and the positive effects reported are placebo effects.

Because there are no medicinal ingredients, there is no way to take a typical homeopathic remedy and, by testing it, determine which remedy it’s supposed to be. All you would find would be sugar. That’s why Health Canada doesn’t require any post-manufacturing quality testing of the remedies it deems “safe and effective” – there’s nothing that can be objectively measured. So whether it’s lead, rabbit vagina (really), or the liver and heart of a duck, once they’re diluted enough, there’s nothing to distinguish one homeopathic remedy from another. Yet each approved product is granted a unique license number by Health Canada.

Homeopathy’s lack of active ingredients gives the products a reasonable safety profile. After all, a product can’t cause side effects, if it doesn’t cause any effects at all. So you can take plutonium, dilute it enough, and you won’t get radiation poisoning. But when a homeopathic remedy isn’t diluted enough, you can be exposed to the initial substance, which can be toxic. Enter Hyland’s Teething Tablets, and a recent warning from Health Canada:Continue reading →

Homeopathy is on the ropes around the world as calls continue to grow for its ejection from all parts of the health care system. Everywhere it seems, but Canada, where the TV show Canada AM gave a completely credulous forum to a homeopath advocating various “remedies” for first aid. Kim Hebert says more over at Skeptic North.

Pharmacy Practice: Among the “alternative” medicine websites, Natural News is among the worst, and often reads like a parody. How’s this for rhetoric about pharmacists that work in oncology:

For decades, they simply looked the other way, pretending they were playing a valuable role in our system of “modern” medicine, not admitting they were actually doling out chemicals that killed people. Now, the sobering truth has struck them hard: They are in the business of death, and it is killing them off, one by one.